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Case Presentation
A 65-year-old woman with hypertension, diabetes mellitus, and asthma presented to the emergency department with the acute onset of shortness of breath. Over the prior 6 months, she has had 3 similar presentations. Each time, she has been admitted and treated with diuretics and bronchodilators, with improved symptoms. She follows up in clinic regularly.
On admission, her blood pressure is 156/88 mmHg and heart rate is 89 bpm. Her body mass index is 38 kg/m2. She appears to be in respiratory distress. Her jugular venous pressure is not visible due to body habitus. She has diffuse crackles in the lungs with 2+ pitting edema.
Chest X-ray shows enlarged pulmonary arteries with bilateral infiltrates suggestive of pneumonia versus pulmonary edema. Echocardiography shows a small left ventricle with a sigmoid septum and an ejection fraction of 30%, borderline right ventricular dilatation, mild-moderate mitral regurgitation, and mild tricuspid regurgitation. Estimated right ventricular systolic pressure is 40 mmHg. She is started on intravenous furosemide and inhaled albuterol and ipratropium. Despite this treatment, she remains dyspneic, and subsequent laboratory studies reveal an increase in creatinine from 1.2 to 1.8 mg/dL. Her pro-B-type natriuretic peptide level was 1000 ng/dL. Blood gas showed pH of 7.10, PCO2 of 70 mmHg, PaO2 of 69 mmHg, and serum bicarbonate of 28 mmol/L. The patient was admitted to the coronary care unit for heart failure exacerbation and was initiated on bilevel positive airway pressure (BiPAP) for respiratory distress.
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KEY POINTS
In heart failure patients, BiPAP has been shown to improve symptom relief, intensive care unit and hospital length of stay, and ultimately quality of life.
Coronary care unit physicians should familiarize themselves with respiratory devices used in day-to-day patient care.
Mechanical ventilation has become sophisticated and is used to improve patient hemodynamics with less risk of lung injury.
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TYPES OF RESPIRATORY SUPPORT DEVICES
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In coronary care units, several devices are used for airway support and are considered vital components. They can be invasive or noninvasive depending on the clinical condition and patient’s wishes.
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Noninvasive Ventilation for Acute Respiratory Failure
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Noninvasive ventilation (NIV) avoids the use of endotracheal intubation and helps reduce the work of breathing by offloading the respiratory muscles. It improves the alveolar gas exchange, improves the alveolar ventilation, and prevents the closure of the upper airway. It can be used via different interfaces, primarily face masks, oronasal face masks, or helmets.1
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A Cochrane review included 14 randomized controlled trials comparing NIV plus usual care versus usual care alone. The use of NIV has shown a decreased need for intubation, with a relative risk (RR) of 0.41 (95% ...